Impact of Intravascular Imaging on Clinical Outcomes in Focal Versus Diffuse Coronary Artery Disease

BACKGROUND: Intravascular imaging (IVI) during percutaneous coronary intervention (PCI) improves outcomes. Pullback pressure gradient (PPG) characterizes coronary artery disease patterns as focal or diffuse; however, the benefit of IVI across this spectrum remains incompletely understood. We aimed to evaluate clinical outcomes after PCI with or without IVI guidance in patients with focal and diffuse disease defined by PPG. METHODS: Prospective, multicenter, single-arm study of 811 patients (840 vessels) undergoing PCI. PPG was calculated from manual fractional flow reserve pullbacks to define focal (PPG ≥0.62) or diffuse coronary artery disease. IVI use was at the operator’s discretion. The primary outcome was target vessel failure at 1-year follow-up. RESULTS: IVI-guided PCI was performed in 41% of patients. In the overall cohort, target vessel failure was lower with IVI guidance (adjusted hazard ratio, 0.60 [95% CI 0.36–0.99]; P =0.044), with a lower incidence of cardiac death ( P =0.042). IVI significantly reduced target vessel failure in focal disease (unadjusted HR, 0.41 [95% CI, 0.18–0.91]; P =0.029), whereas no difference was observed in diffuse disease (unadjusted HR, 0.91 [95% CI, 0.48–1.73]; P =0.771). There was no interaction between PPG and IVI guidance for target vessel failure ( P for interaction=0.128). CONCLUSIONS: In patients undergoing physiology-guided PCI, the use of IVI reduced clinical events at 1 year. These findings suggest that the benefit of IVI extends across the full spectrum of coronary artery disease.